Treatment of a Patient

Transcription

1 Treatment of a Patient with Complete digeorge/charge Syndrome Aleš Janda, Ester Mejstříková, Kateřina Zdráhalová, Ondřej Hrušák, Tomáš Kalina, Zuzana Sieglová, Hana Žižková, Renata Formátnková, Petra Keslová, Anna Šedivá, Jiřina Bartůňková, Karel Dlask, Jan Starý, Petr Sedláček University Hospital Motol, Charles University, Prague, Czech Republic ales.janda@lfmotol.cuni.cz

2 Menu 1. DiGeorge Syndrome (DGS) 2. CHARGE Syndrome 3. Treatment of a complete form of DGS (cdgs) 4. Case report

3 Syndrome DiGeorge 1967 Dr Angelo digeorge defined by phenotype DGS triad congenital heart defects immune deficiency secondary to a/hypo/plasia of thymus hypocalcaemia due to small or absent parathyroid glands initially considered rare current estimate: 1 in 4,000 live births monoallelic microdeletion 22q11.2 (90% of cases) the most common microdeletion syndrome in humans

4 Nomenclature DGS VCFS CTAFS DiGeorge Syndrome VeloCardioFacial Syndrome (Shprintzen) ConoTruncal Anomaly Face Syndrome (Takao) same entity because of del22q11

5 CATCH 22 or 22q11 deletion syndrome? CATCH 22 Cardiac defects, Abnormal face, Thymic hypo/aplasia, Cleft palate, Hypocalcemia, deletion 22q11 negative connotations (Joseph Heller s book) pessimism, self-dispair 22q11 deletion syndrome probably better for description of this condition

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7 22q11 region The common 3 Mb typically deleted region (85% of del22q11 patients) the 1.5-Mb deletion (8% of patients) a f Individual patients with unusual deletions Lindsay, Nature Reviews Genetics 2; (2001)

8 DGS without 22q11.2 deletion only 10% of pts with DGS lack 22q11.2 deletion environmental factors (foetal exposure): alcohol retinoic acid maternal diabetes other genetic factors: del10p13 del17p13

9 Complete DiGeorge Syndrome (cdgs) in 1-5 % patients with DGS severe immunodeficiency aplasia of thymus no or very low number of T cells fatal if left untreated <50% patients have del22q11.2

10 CHARGE Syndrome Coloboma Heart defects Atresia choanae Retarded growth Genital anomalies Ear anomalies

11 CHARGE Chromodomain Helicase DNA-binding the origin of CHARGE remains indefinite, however, CHD7 gene at locus 8q12 is currently being investigated as a candidate gene the chief phenotypical features of CHARGE distinguishing it from DGS are coloboma and choanal atresia as these are uncommon findings in DGS or 22q11.2 deletion phenotypes

12 CHARGE + cdgs overlapping phenotype? stand-alone entity? usually no 22q11.2 deletion

13 Possible therapeutical approaches in patients with cdgs thymus transplantation bone marrow transplantation (BMT) peripheral blood monocyte cells transplantation (PBMCT) X palliative approach ethical dilemma?

14 Transplantation of thymus post-natal thymus tissue (from infants younger than 6 months) no HLA match, however, pts with closest HLA matching developed the T cells more rapidly all pts developed T-cell proliferative responses to mitogens pts have many infections in the first 100 days after the transplantation 12 pts, 58% survival with 15 months to 8.5 years of follow-up good result in comparison with SCID treated with BMT (survival 75-80%), these pts with no major congenital abnormalies (e.g. heart defect, etc.) not available in Europe? 5 pts with CHARGE transplanted, 3 pts died (intracerebral hemorrhage, hemorrhage during abdominal surgery, sepsis) Markert, M. L. et al. Thymus transplantation in complete DiGeorge syndrome: immunologic and safety evaluations in 12 patients. Blood 102, (2003).

15 Bone Marrow Transplantation 7 months, female, 1.2x10 9 /kg of from brother (DR mismatch) no conditioning, no GVHD profylaxis T cell engraftment, CD4>400 cells/ul after 12 months PHA normal - in couple of months, normal response to vaccination clinically ok, developmental delay, several episodes of otitis media, Shigella gastroenteritis well after 3 years post-bmt Goldsobel, A.: Bone marrow transplantation in DiGeorge syndrome. J Pediatr 111, (1987)

16 BMT 2 5 months, female, 4.3x10 8 cells/kg from HLA-identical brother no conditioning, no GVHD prophylaxis T cell engraftment, CD4>400 cells/ul after 1 month PHA normal after 8 months well after 2 years post-bmt Borzy, M.: Successful bone marrow transaplantation with split lymphoid chimerism in DiGeorge syndrome. J Clin Immunol 9, (1989)

17 BMT 3 13 months, 8.0x10 8 cells/kg, HLA-identical sibling, ratg insuficient no engraftment 19 months, busulfan, cyclophosphamide, CyA+MTX GVHD prophylaxis chimerism (D+18), complete engraftment (D+28), CD4>400 cells/ul after 1 month engraftment of mononuclear cells and granulocytes (different from previous cases) PHA normal after 10 months naive (CD4+45RA+) significantly increased did the patient have a thymus? Matsumoto, T. et al. Complete-type DiGeorge syndrome treated by bone marrow transplantation. Bone Marrow Transplant 22, (1998).

18 BMT 4 1 st patient 2 nd 1 haploidentical BMT (T-cell depleted) patient 3 haplo-identical BMT (T-cell depleted) no conditioning, no engraftment 4 th BMT together with thymic tx died died Markert, M. L. et al. Complete DiGeorge syndrome: persistence of profound immunodeficiency. J Pediatr 132, (1998)

19 Why should BMT work in cdgs? induction of thymic differentiation by T cells (?) activation of hypoplastic thymus thymus could be present even if undetected by MRI recent thymic emigrants, thymic hormones expansion of extrathymic T cells (?) increment in gamma/delta T cells Vβ repertoire on CD4+ and CD8+ cells post-thymic precursor cells able to expand in peripheral lymph nodes without contact with thymus, or long-lived T cells were infused from donor, and these cells increase by various means

20 Peripheral Blood Monocyte Cells Transplantation 4 years (!), male, HLA-identical sister, 24x10 6 cells/kg no conditioning, GVHD prophylaxis CyA+mycophenolate mofetil mixed chimerism only in T-cell population, exclusive memory phenotype, absence of TRECs, B and NK cells exclusively of recipient origin PHA normal, specific Ab produced after immunization anti-thyroglobulin autoantibodies disappeared (!?) well after 6 years, stable level of CD3+ cells T cell proliferations to mitogen are still normal Bensoussan, D. et al. T-cell immune constitution after peripheral blood mononuclear cell transplantation in complete DiGeorge syndrome. Br J Haematol 117, (2002)

21 PBMCT 2 2 months, male, HLA matched brother, 10ml of peripheral blood without mobilisation, 4x10 6 CD3+ cells/kg no conditioning, no GVHD prophylaxis 2 nd transplant at 7 months, 2x10 7 CD3+ cells/kg T-cell counts, PHA normal after 1 week, no GVHD good response to immunization CD3+ plateau at 315 cells/ul after 75 weeks no oportunistic infection approx. 50% chimerism Bowers, D.:A. Immune constitution of complete DiGeorge anomaly by transplantation of unmobilized blood monunclera cells. Lancet 352, (1998)

22 Case report

23 Perinatal history Caucasian male born on June 18 th, 2004 healthy parents, no consanguinity, no siblings 1 st pregnancy polyhydramnion amniocentesis normal karyotype 46,XY term delivery, foetal hypoxia Caesarean section resuscitation, intubation, artificial ventilation

24 Symptoms hypertelorism (wide-set eyes) malformed low-set ears micrognatia (small chin) bilateral choanal atresia esophageal atresia with tracheobronchial fistula congenital heart defects (haemodynamically significant ductus arteriosus, right-sided aortal arch and foramen ovale apertum) bilateral retinal coloboma tracheobronchomalacia apnoic pauses severe gastroesofageal reflux retention of testis and micropenis recurrent infections, septicaemia recurrent respiratory distress artificial ventilation absence of T cells 21 cells/µl, no response to mitogens (2 mos) absence of thymus (MRI, surgery)

25 DiGeorge syndrome? low T-cells? yes absent thymus? yes hypocalcemia? yes (however no seizures) heart defect? yes microdeletion at 22q11.2? no (no other genetic tests done)

26 CHARGE Syndrome Coloboma Heart defects Atresia choanae Retarded growth Genital anomalies Ear anomalies yes yes yes yes yes yes

27 Surgical interventions esophageal atresia + TE fistula bilateral choanal atresia congenital heart defects fundoplication insertion of gastric tube

28 1 st BMT at 6 months (4 months after diagnosis) unrelated donor from Canada, 8/10 (B, Cw) no conditioning, no GVHD prophylaxis 1x10 6 /kg CD3+; 0.2x 10 6 /kg CD34+ (bone marrow) non-irradiated blood products administered (7 times prior 1 st BMT, 1 time after 1 st BMT) Chimerism VNTR (D+10) donor detected no other signal detected (transfusions) Complications (D+10) skin agvhd(stage 3, grade II) sepsis, cardiopulmonary instability. capillary leakage sy, ileus

29 2 nd BMT at 7 months, D+36 after 1 st BMT 0.89x 10 6 /kg CD3+, the same donor, no conditioning prevention of GVHD: CsA EBV infection D+27 B cell proliferation oligoclonality no clinical manifestation withdrawal of CsA rituximab (375 mg/m 2 ) proliferation of CD8+ activated T cells started Complications liver GVHD agranulocytosis

30 T cells on Log scale BMT 2 nd BMT

31 Memory versus Naive T cells

32 Current status D+517 after 1st DLI, age 22 months out-patient mode no infections normal liver function slight gradual psychomotorical development apnoic pauses now rarely immunosuppression stopped IVIG stopped problem with feeding (via gastric tube)

33 Problems patient may face in the future exhaustion of the graft, apoptosis o increased susceptibility of CD4+ cells to apoptosis following stimulation (regulatory effect o loss of part of relevant T-cell repertoire autoimmunity o due to exclusive peripheral expansion of T cells without thymic selection o continuous thymic output ensures that self-reactive T-cells are maintained at a very low frequencies in the periphery problems caused by other abnormalities

34 Conclusion low dose BMT from unrelated donor in patients with DGS is a functional treatment alternative option care for the patients with complete DGS is very difficult as they suffer from various serious medical problems and poor immunological status is only one of them

35 ...and his former home our patient...

36 Acknowledgements K. Zdráhalová, P. Sedláček, O. Hrušák, E. Mejstříková, R. Formánková, T. Kalina, P. Keslová, J. Starý Department of Paediatric Haematology and Oncology A. Šedivá, J. Bartůňková Department of Immunology D. Blažek, K. Dlask Department of Anesthesiology H. Žižková, S. Žilovcová, Z. Sieglová Institute of Haematology and Blood Transfusion